Socio-Demographic Determinants of Vaccine Coverage For

International Journal of TROPICAL DISEASE & Health

39(3): 1-13, 2019; Article no.IJTDH.52839 ISSN: 2278–1005, NLM ID: 101632866

Socio-demographic Determinants of Vaccine Coverage for Pneumococcus and Rotavirus among under Five Children in Busolwe Town Council, Butaleja District, Eastern Uganda: A Cross Sectional Study

Brenda Wafana Nabwana1, Sylvia Sidney Namayanja1, Collette Kemigisha1, Erina Kisakye1, Amos Kuddiza Kusetula1, Silvester Wakabi1, Ivan Wambi2, Innocent Musiime2, Rebecca Nekaka1 and Yahaya Gavamukulya3*

1Department of Community and Public Health, Faculty of Health Sciences, Busitema University, P.O.Box 1460, Mbale, Uganda. 2Busolwe General Hospital, Butaleja District Local Government, Butaleja District, Uganda. 3Department of Biochemistry and Molecular Biology, Faculty of Health Sciences, Busitema University, P.O.Box 1460, Mbale, Uganda.

Authors’ contributions

This work was carried out in collaboration among all authors. Authors BWN, SSN, CK, EK, AKK and SW conceived, designed the study, participated in data collection, analysis and manuscript writing. Authors IW and IM supervised the data collection and analysis. Author RN participated in the study conception, design, coordinated the entire COBERS program and reviewed the manuscript. Author YG was a research mentor and supervisor who participated in the study conception, design, preparation for approval and proof reading of the final results and manuscript. All authors read and approved the final version of the manuscript.

Article Information

DOI: 10.9734/IJTDH/2019/v39i330209 Editor(s): (1) Dr. Thomas I. Nathaniel, Department of Biomedical Sciences, School of Medicine -Greenville, University of South Carolina, Greenville, USA. Reviewers: (1) Giuseppe Gregori, Italy. (2) Indianara Maria Grando, Brazil. Complete Peer review History: http://www.sdiarticle4.com/review-history/52839

Received 28 September 2019 Original Research Article Accepted 03 December 2019 Published 07 December 2019

ABSTRACT

Background and Aims: There is a high burden of vaccine-preventable diseases in the children under five years of age, particularly pneumonia diarrhea and which is greatly affected by low immunization coverage despite the existing efforts and policies. This study was carried out in ______

*Corresponding author: Email: [email protected];

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Butaleja district and was aimed at establishing the socio-demographic determinants of vaccine coverage for pneumococcus and rotavirus among under five children (U5C) in the district. Study Design: This was a mixed methods cross-sectional study. Place and Duration of Study: Busolwe Town Council, Butaleja District, Eastern Uganda. Methodology: Structured researcher administered questionnaires were administered to 434 caregivers of U5C in different parts of Butaleja district. In-depth interviews with key informants and focused group discussions with Village Health Teams and community members were conducted. Review of Health Management Information Systems records was done. STATA 15 was used to analyze the data. Results: The study found that there is a declining trend in completion of the doses of Pneumococcal vaccine (PCV) and Rotavirus vaccine. For example, in quarter 1 of 2019, out of the 312 children who started immunization, only 2 completed Rota virus immunization and only 117 completed PCV vaccinations a trend that has been observed since 2016. The factors that showed a significant association with the the fact that they gave their child at least one dose of the vaccine were having been sensitized on the current immunisation schedule(P-value = <0.001), misunderstanding that vaccine is harmful for child (P-value = 0.007), willingness to take children to vaccination (P-value = <0.001), and social factors such as family (P-value = <0.030). Gender also played a key determinant role where the children’s fathers lacked knowledge on significance of immunization and thus discouraged the mothers from taking the children for immunization. Inadequate funding was also highlighted from the Focus Group Discussions. Conclusion: Vaccine coverage for pneumococcus and rotavirus is still low in Butaleja district mainly due to the attitudes and perceptions of caregivers as well as the knowledge gap. There is need for extensive sensitization of all community members to enable them understand the significance of immunization. It would further be important to increase the funding of the immunization programme to intensify and ensure effectual outreaches as well as the establishment and enforcement of a policy for immunization compliance.

Keywords: Vaccine coverage; Pneumococcus Vaccine (PCV); rotavirus vaccine; under five children (U5C); Butaleja; Eastern Uganda; COBERS; knowledge.

ABBREVIATIONS effort, over 24,000 children die of vaccine- preventable diseases every day around the world BUFHS-HDRC : BUFHS Busitema University equivalent to 1 child dying every 3.6 seconds, Faculty of Health Sciences 16-17 children dying every minute, and just about Higher Degrees and Research 9 million children dying every year. In 2008 there Committee was a bigger proportion of deaths in sub- COBERS : Community Based Education, Saharan Africa (4.4 million) and South Asia (2.8 Research and Services million) compared to Latin America, the HMIS : Health Management Caribbean, and industrialized countries (0.1 Information Systems million) [2]. PCV : Pneumococcal Vaccine RHITES-E : Regional Health Integration to Vaccination is key in prevention of some Enhance Services in Eastern infectious diseases as indicated by the reduction Uganda. in incidence rates of invasive pneumococcal U5C : Under Five Children disease were lower after vaccine introduction. It VHTs : Village Health Teams was noted that the incidence rates of pneumococcal invasive disease were 19.0 cases 1. INTRODUCTION per 100,000 for whites, 54.9 for blacks, and 13.7 for other racial groups compared to 2002,where Immunization is the process whereby a person is the incidence rates of pneumococcal invasive made immune or resistant to an infectious disease were 12.1 for whites, 26.5 for blacks, disease, typically by the administration of a and 5.6 for other racial group as obtained from vaccine [1]. The World Health Organization Analysis of data from the Active Bacterial (WHO) launched the Expanded Program for Core Surveillance (ABCs)/Emerging Infections Immunization (EPI) in 1974, and many Program Network, an active, population-based developing countries adopted it. Despite this surveillance system in 7 states. Patients were 15

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923 persons with invasive pneumococcal should this issue remain unaddressed as disease occurring between January 1, 1998, and evidenced by the current measles outbreaks. December 31, 2002. Furthermore, there seems to be a gap in information and statistics on district specific Additionally, the incidence of Pneumonia is immunization coverage data for some districts. estimated at 0.29 episodes per child which To address this issue awareness is key but for equals 21% of deaths in under five children in this to be achieved, the root cause of this developing countries [3]. Furthermore, the problem should be recognized and the missing prevalence of diarrhea, according to Uganda link or gap can be closed up. It was also Demographic Health Survey (UDHS 2011) done important to assess the standpoint of the by Uganda Bureau of Statistics is estimated at community members to discover why the 23% [4,5]. Busolwe District Hospital records community members did not take their children indicate an increase in the prevalence of both for immunization even when the services were diarrhea and pneumonia despite all efforts to do availed. away with these diseases. Low vaccine coverage has been highly associated to this trend. The aim of this study was therefore to determine the factors associated with vaccine coverage DPT3-Hib3-Heb3 coverage in 2017/18 was at particularly for PCV and Rota Virus vaccine in 95% and measles coverage was 88% in 2016/17 order to provide evidence-based education and and still below the target of 95% in Uganda [5]. sensitization to the community and thus reduce However, the DPT3 coverage showed a decline the prevalence and risks associated with vaccine from 99.2% in 2016/17 [6]. Some districts hesitancy and low immunization coverage in showed a lower than 60 percent measles Butaleja district, Eastern Uganda. coverage for example Nakasongola 59%, Mayuge 58.4%, Apac 58.2%, Bukomansimbi 2. MATERIALS AND METHODS 55.5%, Bulambuli 53.6% and Amudat 53.4% [6]. There seems to be lack of statistical information 2.1 Study Area and Target Population on immunization coverage for some districts and most the information is generalized. The study was carried out in Butaleja District in Eastern Uganda which is bordered by Budaka Low immunization coverage and vaccine and Kibuku districts in the North, Mbale in the hesitancy in Uganda and Butaleja district East, Tororo district in the South East and specifically, has been in existence but has not Namutumba in the West, as shown in Fig. 1 [4]. been solved yet it is set as one of the ten major Butaleja district has a total population of 244153 health threats in 2019 by the World Health people of which 119466 (48.9%) are males and Organization. In a study done in Busolwe aimed 124687 (51.1%) females according to the at determining the knowledge and perception of national population census 2014. It also has a caregivers about risk factors and manifestations population of 50448 of children under five [4,5]. of pneumonia among under five children in The Busolwe General Hospital has a catchment Butaleja district, for the 302 respondents it was population of 42298 people, with women in found that among the caregivers’ children only 39 childbearing age being 8544, with number of percent were fully immunized, 56 percent pregnancies being 2114, number of live births partially immunized and 5 percent were not 2051; number under five years is 8544. immunized [7]. 2.2 Study Design Low immunization coverage is further set to be a major cause of childhood mortality if not The study included: A Cross-Sectional Study addressed since these childhood diseases are among sample population which was done in two set to have a negative impact on children health phases. The first phase was a pilot study which in absence of complete immunization for aimed at ascertaining the community diagnosis example pneumonia accounted for 14 percent of of the Busolwe District Hospital Catchment Area mortality (third major cause) in children under 5 between June to July, 2018. The second phase in 2017 and diarrheal diseases associated with which included Data Collection of Vaccine Rota Virus accounting for 4500,000 deaths each coverage for pneumococcus and rotavirus was year with 95 percent in poor communities [5]. done from 8th april,2019 to 3rd may,2019. Primary There is likely to be an increase in the vaccine data collected using interviewer- administered preventable disease outbreaks in the community questionnaires to a total of 434 care takers of

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children under five years of age, whereby 402 years, and 8 females of which all of them were were female and 32 were male in the households married. All participants in the FGD were of Budumba, Bubalya, Kachonga sub-counties caretakers of children under five who agreed to and Busolwe Town council in Butaleja district. take part in the study, by giving informed consent. Secondary data from Health Management Information Systems (HMIS) records of of 2.3 Sample Size Determination Vaccine coverage for pneumococcus and rotavirus of 2016, 2018 and 2019(Jan to March) The minimum sample size was determined using for Busolwe District Hospital. 2 2 the Cochran’s formula N = (1.96) pq/d , with a 2 Focus Group Discussions (FGD) were held; the confidence level of approximately 95% (1.96). first one on the 10th April, 2019 in Dundo village, Where, N = required sample size, P = proportion Busolwe Town Council, Butalejja district. A total of population having the characteristics of 15 interviewees participated in the session of considering recent studies, q = (1-p) and d= (+/- which 2 were married males in the age group of 5%) degree of precision. Therefore, considering 30-38, and the 13 participants were females; 3 0f findings from a current study on Knowledge and whom were unmarried and the 10 females were Perception of Caregivers about Risk Factors and married. Manifestations of Pneumonia among Under Five Children in Butaleja District, Eastern Uganda [7]. th The second FGD was held on the 18 of April in p = 53.7, q = 1-0.537, d = 5/100 = 0.05. Thus, N Budumba village near Budumba health Centre = [(1.96)2 x 0.537x 0.463] / (0.05)2= 0.9551 / III, in Butaleja district during one of immunisation 0.0025= 382 participants.In order to reduce community outreach programmes. A total of 11 errors, the sample population was enlarged from interviewees participated, where by 3 of these 382 participants to 434 participants. were married males in the age groups 0f 40-45

Fig. 1. A map of Uganda showing the location of Butaleja district [4]

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2.4 Sampling Strategy stored online, and access to it was limited to only three administrators. Homogeneous purposive sampling method was used. Recruitment was by the VHT leaders and 2.8 Data Analysis members introducing the students to the community, particularly to homes or households The data was analyzed using STATA version 15 they knew to have at least one child under the that is “StataCorp.2017.Stata Statistical, Release age of five. 15. College Station, TX: Stata Corp LLC.” Socio- psychological factors of care givers which could 2.5 Inclusion and Exclusion Criteria correlate with of the fact that they gave their child at least one dose of vaccine were evaluated by Inclusion into the study required one to be a chi square test or Fischer's exact test. P value parent (mother or father) and/or caretaker of the <0.05 were considered statistically significant. In under-five child (ren) in the community or facility- case the expected frequency was less than 5, Busolwe District Hospital; who has given Fisher`s exact test was performed. informed consent, whereby both the literate (381participants) and illiterate (53participants) we 3. RESULTS AND DISCUSSION explained to the purpose of the study and thereafter asked to consent either by signing the 3.1 Results consent forms or by using thumb print respectively. Exclusion from the study was to any Vaccine Coverage Trend of Pneumococcus and though being parent(s) and/or caretaker to the Rota virus from 2016 to 2019. There is a under-five child (ren), if they refused to give decrease in the number of children who receive informed consent. the last doses of both PCV and Rota virus immunization compared to those who actually 2.6 Data Collection start the doses, as showed by the BCG results, since this vaccine is given at birth. In 2016, 169 2.6.1 Primary data sources children started on immunization at birth with

We developed an electronic data collection and BCG versus the 91 children who completed the entry (storage) tool in form of Google forms on last dose of PCV. This trend follows through to tablets, smart phones and even laptop 2019 (January to March) whereby 312 children computers, from which the researcher started on BCG and only 2 and 117 completed administered questionnaire was used to assess the doses of Rota virus and PCV respectively as the perceptions and attitudes of the different shown in Fig. 2. Thus, BCG is being used as a correspondents towards the immunizable reference standard for the children who were diseases as well as the factors associated with started on immunization in that period. the immunization coverage in Butaleja district In 2016, 109 children started immunization of [8,9]. The Google form was developed at PCV1, 102 received PCV2, and only 91 returned Google Inc. and could be easily accessed at for PCV3. In 2018, 168 received PCV1, 140 the following universal resource locator PCV2, 108 PCV3 indicating 60 children didn’t (https://forms.gle/PCi5rbK1mt5tgzhA8). The finish their immunization. In 2019, 153 children questionnaire was pretested and validated nd were started on PCV1, of these 120 received among 2 year Medical and Nursing students at PCV2, and only 117 received PCV 3, showing BUFHS, who had taken part in the pilot study that 36 children didn’t finish immunization of PCV before the data collection process, and also (Fig. 2). because the these questionnaires were interviewer-administered. For Rota virus immunization; in 2018, 168 children received Rota1, 133 Rota2, and only 14 2.6.2 Secondary data sources received Rota3, indicating that 119 children did not complete immunization for Rota virus. In Some of the data was collected from the 2019, 102 children started immunization of Busolwe district hospital HMIS records. Rota1, 80 received Rota2, and only 2 received Rota3, indicating 100 children who didn’t 2.7 Data Storage complete immunization for Rota virus. In comparison with 2016, it is noted that there has The raw data collected on questionnaires been almost no change in the trend with regards (Google forms) was automatically and securely to completion of vaccination.

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350

300 d e z i

n 250 u m m I

e 200 r d l i h c

h 150 t

f o

r e

b 100 m u N

0 BCG PCV1 PCV2 PCV3 ROTA 1 ROTA 2 ROTA 3 Immunization Vaccines

2016 2018(oct to dec) 2019(jan to march)

Fig. 2. A graph showing the number of children immunized per quarter for subsequent doses of the immunization vaccines

Table 1. A table representing the socio-demographic characteristics of participants in the study

Demographic characteristics Freq. Percent Sex Female 402 92.63 Male 32 7.37 Marrital status Married 413 95.16 Not Married 21 4.84 Education level Certificate course 7 1.61 Diploma level 3 0.69 Primary 269 61.98 Secondary (A’ level) 4 0.92 Secondary (O'level) 97 22.35 Uneducated 53 12.21 University 1 0.23 Place of residence Town 68 15.67 Trading Centre 98 22.58 Village 268 61.75 Religion Anglican 115 26.5 Born Again Christian 29 6.68 Catholic 50 11.52 Muslim 232 53.46 SDA 8 1.84

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Socio-Demographic Characteristics of In regards to pneumonia and diarrhea, for Participants: A total of 434 caregivers diarrhea only 24.65% believed it could be participated in the study on immunization prevented by immunization, and the rest by coverage of PCV and Rota Virus vaccine and its washing hands before drinking and eating, determinants out of which (402) 92.63% were 50.69%, 22.35% did not know. For pneumonia it female and (32) 7.37% were male. The majority was perceived that only 35.94% believed it could of the respondents (413) 95.16% were married be prevented by immunization, putting on warm and the other (21) 4.84% were not married. In clothes 28.34% and 31.57 % did not know. terms of education, majority were primary school dropouts; (269) 61.98%, (97) 22.35% at The factors that showed a significant association secondary O’ level and (53) 12.21% were with the the fact that they gave their child at least uneducated. Only 15 had pursued education one dose of the vaccine were knowledge (P- beyond O’ level that is diploma, certificate, A’ value = <0.001), beliefs and perceptions (P-value level or University as shown in Table 1.The = 0.007), attitudes (P-value = <0.001), and social major religion in the community was Islam (232) factors such as family (P-value = <0.030) as 53.46%, Anglicans were (115) 26.5%, Catholics shown in Table 4. at (50) 11.52%, Born-Again Christians (29) 6.68 percent and SDAs the least being 1.84%. 3.2 Results from Focus Group Discussion

Knowledge and Perceptions of caregivers of 3.2.1 Problems relating with caregivers children under five about immunization coverage of PCV and Rota virus vaccine: 1) Caregivers fear the health workers, because From Table 2 and Table 3, as large percentage the health workers scold care caregiver when of the respondents (99.54%) claimed to have they lose immunization card, or forget heard about immunization and only 0.46 percent appointment date. As a result, the care giver hadn’t. The commonest source of information does not bring the child for the second dose of was health workers at 87.33%, VHTs (8.33%), the vaccines or even the subsequent ones. mass media (TV and radio) at 3 percent and family members lastly at 1.33%. 2) Husband misunderstand that the vaccines are harmful for the child because the child cries a lot 99.31% knew that immunization helps in on the night of vaccination. Then, husband stops prevention of diseases in comparison with the his wife from taking the child for another dose of minority 0.69% and with 79.49% having the vaccine. mentioned a correct disease, 12.68% mentioned a wrong disease, for example malaria and 7.83% 3) Caregivers misconception that one dose of didn’t know. vaccine is enough. Accordingly, they do not come back for next dose of vaccine resulting in 96.77% knew about the availability of incomplete vaccine protocol. immunization services offered at Busolwe hospital, 2.53 didn’t know while 0.69% claimed 4) Caregivers do not know why children need there were no immunization services. In terms v a c c ination i.e. they do not know that the of access to availability of advice on vaccines prevent children from developing these immunization services, 71.66 percent believed diseases. they had good access, 9.68% said they had poor access to the services while 18.66% did 5) When caregivers get divorced, they move to not know. 69.35% admitted to having o t h e r d i s t r icts, as a result, continuation of vaccine been sensitized on the current immunization protocol becomes difficult. schedule while 30.65% claimed they were not. 6) Negligence by the caregivers. Although the caregivers know necessity of vaccine, they In terms of knowledge, 26.5% of the respondents abandon their responsibility complaining lack of believed a child could fall sick from immunization, time and physical tiredness. 61.29% were against this and 12.21% did not know. Despite this ideology,96.54% of the 7) Most of caregivers have a lot of children, respondents said they would still take their because they lack knowledge about proper children for immunization, 3% said they would family planning method. As a result, they forget not and 0.46% said they were not sure. vaccine schedule on second dose and after,

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because the vaccine schedules are too many to the risk of vaccine preventable diseases [11]. remember for each of children. This is supported by a report by World Health Organization whereby growing level of vaccine 3.2.2 Problems relating with health workers hesitancy were an additional risk to the failure in attaining maximal immunization coverage [12] 1) Health workers also lack knowledge of which is emphasized more by the data collected vaccination and vaccine protocol. thus showing the study area as having greatly substandard vaccine coverage. 3.2.3 Problem relating to funding Non-compliance to the immunization schedule 1) Facilitation of the health workers such as makes the children’s bodies unable to form the lunch and transport is not availed on the intended immune defenses against the childhood scheduled vaccination days because of killer diseases, and this makes them susceptible inadequate of funding by the government. and even easily succumb to these infections which are so widespread in these low-income 2) There are no Permanent place (building) for communities of Butalejja district and eastern vaccination constructed because of lack of fund Uganda at large. of government. As a result, if it rains heavily, vaccination cannot be performed on the The demographic factors also do influence the scheduled date. immunization coverage. It was noted that

3.3 Discussion majority of the care takers were school dropouts who stopped in primary school (61.98%), O’ level Child health and survival are reliant on several (22.35%) and some uneducated (12.21%). factors and these include high immunization Education of the care takers is important as it coverage, however, based on the results of this plays a role in modification of the perception, study, there was a noted decline in the attitude and practices towards immunization as immunization coverage for PCV and Rota virus evidenced by data from the questionnaires vaccines as shown in the results from the HMIS whereby it was observed that even among those data collected from the region of study. This is who took their children for immunization some related to a report by the Uganda Bureau of still believed the children would get sick and this Statistics in 2017 where there was also a noted could be attributed to the low education level. decline in coverage for subsequent doses with Since some of these are basics taught in school. 79% of the children receiving the recommended This is likened to a cohort study on how Maternal doses of the DPT- HepB- Hib, 66% the three education is associated with vaccination status of doses of polio and 64% the three doses of infants less than 6 months in Eastern Uganda, pneumococcal vaccine [10]. where by Infants whose mothers had a secondary education were at least 50% less Additionally, as one of the national challenges, it likely to miss scheduled vaccinations compared was noted that no district has reached the full to those whose mothers only had primary immunization coverage of 80% for children below education and there was improved primary one year which leaves the children exposed to health care service utilization [13].

Table 2. Knowledge and perceptions of respondents towards immunization

Knowledge and perceptions I don’t know (%) No (%) Yes (%) Have you ever heard about immunization? 0.46 99.54 Can a child get sick from being immunized? 12.21 61.29 26.5 Would you take your child for immunization? 0.46 3 96.54 Do you have any immunization services in Busolwe district 2.53 0.69 96.77 hospital? Have you been sensitized on the current immunization 30.65 69.35 schedule? Does immunization help in the prevention of diseases 0.69 99.31 Do you feel you have good access to the advice you need 18.66 9.68 71.66 on immunization?

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Table 3. Knowledge and perceptions of respondents towards immunization and available sources of information

Question Response Frequency percent Source of Information on Family members 4 1.33 Immunization Health worker 262 87.33 TV/Radio (Mass media) 9 3 VHT 25 8.33 Prevention of diarrhea Others 10 2.3 Don't know 97 22.35 Immunization 107 24.65 Washing hands before eating and drinking 220 50.69 Prevention of pneumonia Don't know 137 31.57 Immunization 156 35.94 Putting on warm clothes 123 28.34 Take to hospital 18 4.15

Table 4. Association of the different factors with the the fact that they gave their child at least one dose of the vaccine

Question / indicator for the factors Have you taken your child for Total P-value immunization (fisher’s No Yes exact) Have you been No 12(80.00) 121(28.88) 133(30.65) sensitized on the Yes 3(20.00) 298(71.12) 301(69.35) current schedule Total 15(100.00) 419(100.00) 434(100.00) <0.001 Can a child get sick I don’t know 2(13.33) 51(12.17) 53(12.21) from immunization No 4(26.67) 262(62.53) 266(61.29) Yes 9(60.00) 106(25.30) 115(26.50) Total 15(100.00) 419(100.00) 434(100.00) 0.007 Do you have good I don’t know 2(13.33) 79(18.85) 81(18.66) access to the advise No 5(33.33) 37(8.83) 42(9.68) you need on Yes 8(53.33) 303(72.32) 311(71.66) immunization Total 15(100.00) 419(100.00) 434(100.00) 0.018 Would you take your I don’t know 0(0.00) 2(0.48) 2(0.46) child for No 6(40.00) 7(1.67) 13(3.00) immunization Yes 9(60.00) 410(97.85) 419(96.94) Total 15(100.00) 419(100.00) 434(100.00) <0.001 Family type Extended 3(20.00) 1105(25.06) 108(24.88) Monogamous 0(0.00) 12(2.86) 12(2.76) Nuclear 9(60.00) 252(60.14) 261(60.14) Polygamous 1(6.67) 48(11.46) 49(11.29) Sibling household 2(13.33) 2(0.48) 4(0.92) Total 15(100.00) 419(100.00) 434(100.00) 0.030

Low education level (maternal and paternal) was maternal education accounted for a high noted as one of the main factors associated with likelihood of child vaccination [16]. under vaccination of children [14]. In another study, immunization coverage was also Age of the care takers has an impact on associated with educational level of the father participation in immunization thus influencing and the mother. Children whose mothers’ immunization coverage for example from this education level was at least primary school were study’s findings, the biggest number of more likely to be fully immunized than those participants were in the age bracket 20-30, and it whose mothers had no education [15]. Related was noted these started giving birth as early as studies in Zimbabwe have also shown that 16 years old to an extent, impacts immunization

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coverage where by teenage mothers have a poor prenatal and postnatal lessons taken where the compliance to immunization since they are timid, importance of timely immunization is emphasized ignorant about the immunization schedule and [18]. In another study, one of the predisposing thus they cannot partake in what they don’t characteristics to inconsistencies in immunization know. This is related to a study by Mukungwa in status of children was marital status [16]. Another 2015 on Factors Associated with full study indicates that marital status is significantly Immunization Coverage amongst children aged associated with non-completion of the 12 – 23 months in Zimbabwe whereby the immunization schedule by children less than five likelihood of childhood immunization correlates years [19]. Relatedly, marital status was with maternal age since more experience is identified to consistently influence immunization accumulated over time on importances of uptake and completion rates [20]. immunization and problems associated with lack of immunization [16]. Similarly, maternal age was Despite the existing efforts by the different stake given as one of the factors which have a holders to educate people about immunization, significant association with childhood there is still a knowledge gap on the specifics of immunization on Uganda [17]. the immunization schedule among the care takers as a 59.91 and 73.04 percent of the In a related study to measure full immunization participants did not know that pneumonia and status and associated factors among children diarrhea respectively, could be prevented via aged 12-23 months old in Hosanna Town, South immunization. This still agrees with a study on Ethiopia showed that age of mothers had Knowledge and Perception of Caregivers about significant association with immunization status Risk Factors and Manifestations of Pneumonia of the children [2]. Age of respondents was among Under Five Children in Butaleja District, stated as a very important demographic factor in Eastern Uganda, where many of the respondents affecting immunization coverage in a study do were not knowledgeable about the causes of describe immunization coverage for DPT, Polio pneumonia with only 7.6% believing it to be and Measles among children of ages between 12 preventable by immunization [7]. to 18 months in Kawempe Division and to investigate factors associated with Immunization Similarly, a study in Kawempe-Uganda, on coverage [15]. immunization coverage and factors associated with failure to complete childhood immunization From this study, marital status had a significant showed that the knowledge on immunization association with immunization coverage, where activities enhances the use of immunization by 95.16 percent were married and 4.84 percent services [15]. Another study on assessment of were unmarried. Of these, majority of the child immunization coverage and its children belonging to unmarried couples were determinants showed that children whose either partially or completely unimmunized due to mothers had good knowledge on vaccines were the unsettled nature of the mothers as they move 2.5 times more likely to be fully vaccinated that from family to family and abandon the children children of mothers who had poor knowledge on with their grandparents, while some lose the vaccines [21]. Additionally, a similar study on immunization cards (most people in this study Factors influencing childhood immunization lacked cards) and others fear to continue points out lack of knowledge as a key factor [22]. immunization in the new areas to which they have moved or migrated. This goes hand in hand The focus group discussions revealed key with attendance of Antenatal services during problems relating with care givers, health pregnancy, whereby married women were more workers and to funding. These three categories likely than the unmarried to attend these of problems are very rich and impactful in the services. In this particular study, 98.39 percent of results of the vaccination coverage and the participants believed antenatal services are corroborate with many articles that have been important in ensuring immunization of the infant cited. Most importantly is that they demonstrate a while 1.61 percent thought otherwise. This is wide knowledge gap that is clearly graded supported by a Community-based cross- between the illiterate and the literate caregivers. sectional study done on Timeliness of Childhood Furthermore, it is not unsurprising to reveal that Vaccinations in Kampala Uganda whereby some of the health workers lack the necessary Mothers who sought prenatal and postnatal care information in relation to vaccination which would had a higher likelihood of their children being be mostly due to the heavy workload and immunized which is attributed to sensitization in changing schedules a problem that underscores

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the need for continuous professional CONSENT development and increased funding. Written informed consent from caretakers of the 4. CONCLUSION U5C was obtained before they participated in the study. Participants were informed that their Immunization coverage of PCV and Rota virus privacy and confidentiality would be respected vaccines is still low in Butaleja district as and that there was no potential harm associated evidenced by the decline in the trend of the with participating in the study. It was made clear immunization dosages of the above vaccines as to the participants that participation in the study seen from the data reviewed from the HMIS, yet was voluntary and that they were free to opt out low immunization coverage is set as one of the of the study at any time without any negative ten major health threats in 2019 by the World consequences. Health Organization.

This low immunization coverage is attributed to a ETHICAL APPROVAL number of factors such as the existing knowledge gap about the specifics of the The study and all the protocols were approved immunization schedule among the caregivers of and cleared by the Busitema University Faculty children under five which was majorly seen from of Health Sciences Higher Degrees and data from the cross sectional study among the Research Committee (BUFHS-HDRC) as part of sample population, fear of being embarrassed by the Community Based Education, Research and the health workers, inadequate funding to carry Services (COBERS) Program for the 2018/2019 out the outreach programmes and lack of male Academic year under the Course of Community involvement among others as seen in the Diagnosis and Communication Projects. problems relating caregivers, health workers and Permission to conduct the study was sought from funding. However as seen from this study most the District Health Officer Butaleja and the of the gap exists among the caregivers and a link Medical Superintendent of Busolwe Hospital. must be developed between the health workers and care givers. Emphasis should be put in AVAILABILITY OF DATA AND improving the immunization coverage in Butaleja MATERIALS district because pneumonia and diarrhea are highly prevalent diseases in this area especially All data on which the results, discussions and in the rainy season, as this is most likely to result conclusions of this manuscript are drawn are into increased mortality rates among children, contained in the main manuscript. Additional data increased morbidity rates since the immune sets can be accessed via the Mendeley Data systems of the children wouldn’t be strong Repository(http://dx.doi.org/10.17632/zr2w886dg enough and consequently, this poses a big 2.1), where all the data used in the study has financial burden to the country and undermines been deposited [8]. development. FUNDING Key recommendations from the study can include: 1) Extensive sensitization of the This research was funded by Busitema community members on the importance of University Faculty of Health Sciences COBERS immunization, 2) Intensification of health Committee, the Regional Health Integration To education programmes especially on the Enhance Services in Eastern Uganda (RHITES- immunization schedule, 3) Enforcement of the E) Team, as well as the Fogarty International health policy on immunization to improve on Center of the National Institutes of Health, U.S. compliance of the community members, 4) Department of State’s Office of the U.S. Global Increase funding to the immunization budget of AIDS Coordinator and Health Diplomacy the district and 5) Enhancing people’s (S/GAC), and President’s Emergency Plan for knowledge on underlying factors like family AIDS Relief (PEPFAR) under Award Number planning which in the long run affect 1R25TW011213. The funders had no role in immunization coverage.6) Improving male study design, data collection and analysis, partner participation in matters with regards to decision to publish, or preparation of the immunization. 7) Study exploring the health manuscript. The content is solely the professionals' knowledge, attitudes, and responsibility of the authors and does not practices when they receive a child with a late necessarily represent the official views of the vaccine. funders.

Nabwana et al.; IJTDH, 39(3): 1-13, 2019; Article no.IJTDH.52839

ACKNOWLEDGEMENTS 5. Uganda Bureau of Statistics. 2018 Statistical Abstract. Kampala, Uganda; We thank Busitema University Faculty of Health 2018. Sciences Higher Degrees and Research 6. Uganda Ministry of Health. Annual Health Committee (BUFHS-HDRC) which gave in time Sector Perfomance Report. Kampala, to review and approve the proposal and Uganda; 2018. accompanying protocols through The Busitema 7. Aguti B, Kalema G, Lutwama DM, Mawejje University Community Based Education, ML, Mupeyi E, Okanya D, et al. Knowledge Research and Services (COBERS) Committee. and perception of caregivers about risk The COBERS Committee is further thanked for factors and manifestations of pneumonia the funding provided that enabled most of the among under five children in Butaleja study to be conducted. Furthermore, the Authors District, Eastern Uganda. Microbiol Res J would also like to express their explicit thanks to Int. 2018;25:1–11. all the Doctors, Clinical Officers, Senior nursing DOI: 10.9734/MRJI/2018/44179. officers, Laboratory technicians, HMIS personnel, 8. Nabwana WB, Namayanja SS, Kemigisha Village Health Teams and all other staff who C, Kisakye E, Kusetula AK, Wakabi S, et were of great help in our facility-based and al. Data for determinants of immunization community activities. Final thanks go to all the coverage of PCV and rota virus among Volunteers who participated in the study. We under five children in Busolwe Town also further extend our gratitude to the DHO, Council, Butaleja District, Eastern Uganda. CAO, DHE and LCV of Butaleja District for Mendeley Data. 2019;v1. having granted endorsement and acceptance for DOI: 10.17632/zr2w886dg2.1 our interactions in the community, the VHTs and 9. Nabwana WB, Namayanja SS, Kemigisha LCI chairpersons who guided us during our C, Kisakye E, Kusetula AK, Wakabi S, et community activities especially home visits and al. Towards universal health coverage: the RHITES-E team especially Mr. Anoku Patrick Data for determinants of immunization for according us transport and other support coverage of Pneumococcal and Rota virus when called upon. vaccines among under five children in Busolwe Town Council, Butaleja District, COMPETING INTERESTS Eastern Uganda. Data Br. 2019;25: 104269. DOI: 10.1016/j.dib.2019.104269 Authors have declared that no competing 10. World Health Organization, UNICEF. interests exist. Uganda National Expanded Programme On Immunization Multi Year Plan 2012- REFERENCES 2016. Kampala, Uganda: Uganda Ministry of Health; 2012. 1. World Health Organization, Health Topics: 11. Uganda Ministry of Health, UNICEF. What Immunization; 2018. National and District Leaders Need to do Available:https://www.who.int/topics/immu Promotion of Routine Immunisation In nization/en Uganda. Kampala, Uganda; 2015. (Accessed April 26, 2019). 12. World Health Organization. Global vaccine 2. Bizuneh A. Factors affecting fully action plan Report by the Director - immunization status of children aged 12- General. Geneva, Switzerland; 2018. 23 months. J Pregnancy Child Heal. 13. Fadnes LT, Nankabirwa V, Sommerfelt H, 2015;2. Tylleskär T, Tumwine JK, Engebretsen DOI:10.4172/2376-127X.1000185. IMS, et al. Is vaccination coverage a good 3. Onyango D, Kikuvi GM, Amukoye E, indicator of age-appropriate vaccination? A Omolo J. Risk factors of severe prospective study from Uganda. Vaccine. pneumonia among children aged 2-59 2011;29:3564–70. months in western Kenya: A case control DOI:10.1016/j.vaccine.2011.02.093. study. Pan Afr Med J. 2012;13:13:45. 14. Favin M, Steinglass R, Fields R, Banerjee 4. Uganda Bureau of Statistics. The National K, Sawhney M. Why children are not Population and Housing Census 2014. vaccinated : A review of the grey literature. Area Specific Profile Series -Butaleja Int Health. 2012;4:229–38. District. Kampala, Uganda; 2017. DOI:10.1016/j.inhe.2012.07.004.

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